The Cities That Said Yes to Drugs

The Cities That Said Yes to Drugs

Policies that gave addicts clean needles and places to use drugs were intended to reduce harm. They created a “zombie apocalypse.”

Late last year, I walked roughly a mile from downtown Seattle to the working-class neighborhood of Little Saigon and came upon a montage of human despair. An open-air drug market stretched along the intersection of 12th and Jackson: about 250 people, many smoking fentanyl or bent over in the thrall of the drug, tilting as if mid-fall. Three women lay passed out on the sidewalk, their chests slowly rising and falling, while fellow addicts stepped over them and dealers made sales. Young boys, schoolbags on their backs, stood on a far corner and watched.

I walked around the block to the Hoa Mai playground, named for a Vietnamese flower that signifies rebirth. City workers had installed gates to keep drug users away, but at 4 p.m. on a Wednesday, I counted 27 people smoking drugs and nodding off. No children were in sight.

Half a mile to the south, in the Beacon Hill neighborhood, I visited a 10-acre park named after the Filipino nationalist Jose Rizal. It has a playground and the remnants of an apple orchard, and at night you can peer downtown and see the city lights. As I arrived, a drug user squatted next to a child’s slide and relieved himself. Others had set up tents and colonized the park pavilion, where they heated fentanyl on tinfoil and inhaled the fumes with glass pipes. A few went old-school and injected it.

Across the street, I spoke with Angelina Monsegur as she waited at a bus stop. When she was a kid, she told me, she and her father ate candied apples in the park and watched Fourth of July fireworks. A few weeks earlier, she and her 6-year-old daughter had gotten on the bus and seen a man smoking fentanyl on board. “Are you serious?” she’d shouted at him. “My daughter has asthma.” I asked if she had called the police, and she smiled at my naivete. “All the city does is send out teams who hand out aluminum foil and fentanyl pipes.”

Seattle is one of the wealthiest and best-educated cities in the world. It can afford to try various strategies to address its drug epidemic and high rate of fatal overdoses. Yet many of the city’s leaders, apparently supported by voters, view enforcing bans on the open sale and use of narcotics, and forcing addicts off the streets and into treatment, as akin to an act of state repression.

Seattle, like a striking number of other liberal American cities, has embraced a radical form of “harm reduction,” which is more a philosophy about treating addiction than a scientific approach to it. Harm reduction’s adherents hold that police and outreach workers should “meet the addicted where they are,” which is to say without judgment. The New York State Department of Health, a bastion of harm reduction, describes it as a “social movement” committed to “building leadership” among drug users. In these places, de facto and sometimes legal restrictions on narcotics use have been greatly loosened; cities fund teams of workers to hand out drug paraphernalia, and in some rare cases they’ve created dedicated spaces for addicts to shoot up. Meanwhile, police departments struggling with staffing shortages and budget cuts have stopped devoting resources to sweeping users and dealers off the streets or out of parks and playgrounds.

Harm reduction was born 50 years ago of an admirable humanitarian impulse. Its most basic ideas, such as providing clean needles to users, deservedly draw broad support. There’s a debate to be had, though, about whether this approach has saved lives or added to the carnage of America’s terrible drug epidemic. From 2014 to 2024, roughly 862,000 Americans died of drug overdoses, more than twice the toll of the previous decade. Several studies have shown that addicts who shoot up at official injection sites are far less likely to die of overdoses than those who use drugs in, say, alleyways and parks. Over the past decade, however, overdose-death rates climbed sharply in nearly every city where the strongest harm-reduction policies were in place, and even with declines in the past two years, the rates remain well above those of previous decades. From 2016 to 2025, 7,089 people died of overdoses in King County, which includes Seattle—seven times the number of homicides in that period.

Harm reduction isn’t just a problem for addicts. In many cities, the autonomy of drug users has taken precedence over nearly everything and everyone else, not least working-class families like Monsegur’s who must live alongside addicts and accept dystopian decay. Keith Humphreys, a Stanford psychiatry and behavioral-sciences professor and a former adviser to President Obama, supports needle exchanges and opposes the widespread jailing of users. But when he argues that drug policy must take into account the impact on communities, he told me, some critics dismiss him as a reactionary. Their arguments, he said, “sound a lot more like gun rights and vaccine refusal. It’s no longer about the whole population; it’s about the subset who use drugs.”

In recent years, officials in cities such as San Francisco and Philadelphia have moved to rein in the excesses of harm-reduction policies. Nevertheless, these policies retain a powerful hold on public-health and political leaders in blue parts of the country. I witnessed this in visits to Seattle and Burlington, Vermont—two of America’s more progressive cities. Both are afflicted by high overdose rates, overwhelmed police forces, parks and public squares often captive to drug use, and the theft and disorder that accompany all of that. Yet many of their elected officials continue to insist, despite everything, that harm reduction is the most effective and moral solution to addiction.

Harm reduction took root in the 1970s in the Netherlands, where addicts formed unions—the Junkiebond in Rotterdam, for instance—that distributed needles and pushed back against official insistence on abstinence from hard drugs. Not long afterward, this philosophy gained support in some American and Canadian cities. I first encountered it when I reported on a heroin-shooting gallery in Bushwick, Brooklyn, in 1991. The work of harm-reduction advocates at the time undoubtedly saved lives. HIV-infection rates for drug users in Bushwick had reached 50 percent or higher, at a time when that diagnosis was close to a death sentence. Activists risked arrest to distribute clean needles and bleach to disinfect used ones. But some began to argue for a more radical step: There would be less death, they said, if addicts could inject drugs without fear of arrest.

That momentous step came about not in New York but in Vancouver, a city whose political culture was left-wing and libertarian, celebrating the rights of the individual. In 2003, as overdose deaths surged, the Liberal Party of Canada carved out an exemption to federal drug laws and established North America’s first sanctioned injection site, in Vancouver’s Downtown Eastside, a troubled dockside neighborhood. Addicts could bring their heroin and cocaine to a 13-seat center where staff dispensed needles, swabs, and sterile water to cook the drugs and offered advice on vein maintenance. Clinic staff were trained to reverse overdoses, and if that failed, to call a hospital for help.

Initial opinion surveys found broad public support for the center, and it shone like a beacon for some activists, academics, and journalists in the United States and other parts of Canada. A stream of studies and articles celebrated Vancouver’s legal shooting gallery, which resulted in fewer cases of AIDS and other infections, and fewer deaths. Public-health officials coined a nonjudgmental nomenclature that persists to this day. The word addict was stigmatizing; better to refer to people who use drugs. People used rather than abused narcotics. They did not fail a drug test ; they tested positive.

Vancouver’s model spawned dozens of